SAN DIEGO — Most newborns going home from the hospital for the first time are placed incorrectly in their car safety seat, according to a study that found that a worrisome 93% of infants are buckled wrong.

Parents commonly make at least one critical mistake when installing and strapping their babies in car seats, reported presenter Benjamin Hoffman, MD, from Doernbecher Children's Hospital at Oregon Health and Science University in Portland.

The findings, presented here at the American Academy of Pediatrics (AAP) 2014 National Conference and Exhibition, are poignant, considering that car crashes are the leading cause of death for children 1 to 15 years of age, according to the Centers for Disease Control and Prevention.

To estimate the rate of car seat misuse and to determine factors associated with this problem, the investigators randomly sampled 267 caretaker–infant pairs. Parents were asked to put the child in a car seat and a certified child passenger safety technician recorded the results and then helped correct any errors.

The majority — 93% — were found to have committed at least one critical error, 90% made at least two mistakes, and 50% made at least five.

The most common fault was a loose harness, which can lead to injuries related to forward momentum. Another was the position of the retainer clip, which should be at armpit level. If it is too low, the shoulder straps can splay outward and the child could be ejected from the seat. The correct armpit level is "higher than most families feel it should be," said Dr Hoffman. A correctly placed harness can also be hard to gauge. The right fit "is snugger than most think it should be," he added.

In 8% of cases, families had not used the buckle. "They're stressed, they're busy, they're exhausted," explained Dr Hoffman.

Table 1. Most Common Car Seat Errors

Error Percent
Loose harness 68
Low placement of harness clip 33
Wrong harness slot 28
Use of nonregulated product 20
Installation error motion >1 inch 43
Incorrect recline angle 36
Failure to lock seatbelt 23
Misuse of vehicle seat 17


Dr Hoffman said he hopes this study will help convince hospitals to institute new programs. "I'm constantly told that hospitals can't afford to do that, but if you know that 93% of babies are going home incorrectly, and in danger, then you know we can't afford not to," he said.

The researchers found some factors related to the odds of a parent making an error, including ethnicity, insurance type, and education level.

Table 2. Factors Related to Increased Odds for Car Seat Misuse

Factor Odds Ratio 95% Confidence Interval
Hispanic race 4.0 1.2–14.2
Medicaid 6.8 1.5–30.0
Education level (no college) 5.6 1.6–19.7
No prenatal visit with technician 13.2 3.6–48.7


These findings quantify a problem that has long been known, according to Marilyn Bull, MD, neurodevelopment pediatrician at the Riley Hospital for Children at Indiana University Health in Indianapolis, and medical codirector of the hospital's auto safety program. "This is going to be very important in helping direct interventions to correct the problems," she told Medscape Medical News.

In April, the AAP, in concert with several other organizations, released guidelines to help hospitals develop programs to ensure safe child transportation.

Prior to that, the most recent research was a 10-year-old National Highway Traffic Safety Administration study that showed misuse in 73% of all car seats. "Those are the last good data we have," Dr Hoffman said. "The numbers have not improved."

Dr Bull called for all hospitals that care for children, especially those who discharge newborns, to have a child passenger safety program that includes training from a child passenger safety technician, similar to what is outlined in the AAP recommendations. The study results provide a compelling argument for those guidelines, she said. "I think it's extraordinarily timely."

Dr Hoffman and Dr Bull have disclosed no relevant financial relationships.

American Academy of Pediatrics (AAP) 2014 National Conference and Exhibition: Abstract 25919. Presented October 13, 2014.


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